Nursing progress notes cheat sheet

Posted
by ericalin143 ericalin143 (New) New

These are some notes my peers and I tend to write on some brief examples to give you some examples:

ABT therapy: Pt. on ABT tolerating therapy [insert name/dosage/route] with no adverse reactions noted. [temperature and other vitals that you may think is pertinent].

Lung sounds auscultated with findings, skin temperature ( is the patient flushed?) findings.

If on IV: additionally, IV line patent, no s/s of phlebitis and infiltration.

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Other notes:

( refusal of care)

Pt. found to self remove [apparatus] ( such as sling or abductor pillow, very major points of care). Education on [apparatus] ( specifically what you may have explained). Patient states understanding, " jfhsdkfhsjkf" but continues to non-adhere to precautions. Reapproached and stressed importance, patient continues to refuse. [ Other interventions you may have to do to maintain patient safety.] MD called/made aware. Will continue to monitor ( any vitals or pulses that may be pertinent).

Documenting IV and refusal of care has saved my butt many times ( not a lot of phonecalls!) and I hope this helped.

WittySarcasm

WittySarcasm, BSN

Specializes in rehab. Has 10 years experience. 152 Posts

Not only are the above good advice but if they’re on a rehab for PT/OT you can also chart how they transfer and self care. ‘Pt transfers to bathroom with one person assist to stand pivot to wheelchair to toilet and back to bed. Pt needs lifting assist to stand. Is steady on feet. Mod I with all cares and hygiene.’

This has helped show the progress of patients in rehab and how they get better.

Cloud9RN

Cloud9RN, BSN

Specializes in Neurospine MS/ CMSRN. Has 13 years experience. 141 Posts

I am a bit curious. What type of system are you using in your facility for documentation etc?

brada

brada

1 Post

Is there anyone in here that can give me a sample SOAP note for outpatient mental health to include things you do with the patient as far as skills

Edited by brada